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1.
Medicine (Baltimore) ; 100(41): e27515, 2021 Oct 15.
Artigo em Inglês | MEDLINE | ID: mdl-34731139

RESUMO

ABSTRACT: Retrospective cohort studyTo characterize the learning curve of a spine surgeon during the first 2 years of independent practice by comparing to an experienced colleague. To stratify learning curves based on procedure to evaluate the effect of experience on surgical complexity.The learning curve for spine surgery is difficult to quantify, but is useful information for hospital administrators/surgical programs/new graduates, so appropriate expectations and accommodations are considered.Data from a retrospective cohort (2014-2016) were analyzed at a quaternary academic institution servicing a geographically-isolated, mostly rural area. Procedures included anterior cervical discectomy and fusion, posterior cervical decompression and stabilization, single and 2-level posterior lumbar interbody fusion, lumbar discectomy, and laminectomy. Data related to patient demographics, after-hours surgery, and revision surgery were collected. Operative time was the primary outcome measure, with secondary measures including cerebrospinal fluid leak and early re-operation. Time periods were stratified into 6 month quarters (quarter [Q] 1-Q4), with STATA software used for statistical analysis.There were 626 patients meeting inclusion criteria. The senior surgeon had similar operative times throughout the study. The new surgeon demonstrated a decrease in operative time from Q1 to Q4 (158 minutes-119 minutes, P < .05); however, the mean operative time was shorter for the senior surgeon at 2 years (91 minutes, P < .05). The senior surgeon performed more revision surgeries (odds ratio [OR] 2.5 [95% confidence interval [CI] 1.7-3.6]; P < .001). Posterior interbody fusion times remained longer for the new surgeon, while laminectomy surgery was similar to the senior surgeon by 2 years. There were no differences in rates of cerebrospinal fluid leak (OR 1.2 [95% CI 0.6-2.5]; P > .05), nor reoperation (OR 1.16 [95% CI 0.7-1.9]; P > .05) between surgeons.A significant learning curve exists starting spine practice and likely extends beyond the first 2 years for elective operations.


Assuntos
Vazamento de Líquido Cefalorraquidiano/epidemiologia , Associações de Prática Independente/estatística & dados numéricos , Reoperação/estatística & dados numéricos , Coluna Vertebral/cirurgia , Cirurgiões/estatística & dados numéricos , Adulto , Idoso , Canadá/epidemiologia , Vértebras Cervicais/cirurgia , Competência Clínica/estatística & dados numéricos , Descompressão Cirúrgica/métodos , Discotomia/métodos , Discotomia/tendências , Feminino , Humanos , Associações de Prática Independente/tendências , Laminectomia/métodos , Curva de Aprendizado , Vértebras Lombares/cirurgia , Masculino , Pessoa de Meia-Idade , Duração da Cirurgia , Avaliação de Resultados em Cuidados de Saúde , Complicações Pós-Operatórias/epidemiologia , Complicações Pós-Operatórias/cirurgia , Reoperação/tendências , Estudos Retrospectivos , População Rural , Fusão Vertebral/métodos
2.
J Am Assoc Nurse Pract ; 31(5): 288-292, 2019 May.
Artigo em Inglês | MEDLINE | ID: mdl-30829974

RESUMO

Nebraska is a largely rural state with many communities defined as medically underserved by primary care providers. In 2014, the state legislature voted to eliminate the requirement for an integrated practice agreement (IPA) between nurse practitioners (NPs) and physicians. This report describes changes in access to primary health care in rural and underserved areas of Nebraska after removal of the IPA barrier to practice. The report compares the number of primary care NPs working in medically underserved areas before and after the legislation that ended the required IPA. In addition, anecdotes will be provided of NP and patient experiences in rural, NP-owned practices in Nebraska after IPA requirements were eliminated.


Assuntos
Acessibilidade aos Serviços de Saúde/normas , Associações de Prática Independente/legislação & jurisprudência , Profissionais de Enfermagem/legislação & jurisprudência , Acessibilidade aos Serviços de Saúde/legislação & jurisprudência , Humanos , Associações de Prática Independente/tendências , Área Carente de Assistência Médica , Nebraska , Atenção Primária à Saúde/métodos , Serviços de Saúde Rural/tendências
3.
South Med J ; 111(10): 597-600, 2018 10.
Artigo em Inglês | MEDLINE | ID: mdl-30285265

RESUMO

OBJECTIVES: The American Medical Association has reported that 2016 was the first year in which fewer than half (47.1%) of all practicing physicians owned their own practice. Across the United States, there has been consolidation of physicians and hospital and health systems, resulting in questions about the effect of this on healthcare expenditures. The aim of this study was to compare the expenditures per patient between hospital- and health system-affiliated physicians and independent physicians. METHODS: The author used Virginia's new statewide all-payer claims database to analyze expenditures and quality for 3 years for hospital- and health system-affiliated physicians versus independent physicians. The database had all claims statewide for Virginians with individual or group commercial insurance coverage: 1.95 million patients in 2013, 2 million in 2014, and 2.1 million in 2015. The average annual expenditure for each physician was adjusted for average patient condition burden (risk) and differences in geographic input costs using regression analysis. Measures of primary care quality were obtained from the claims data using evidence-based measures from national health quality organizations. RESULTS: Hospital- and health system-affiliated physicians had annual expenditures per patient ranging from 10.3% to 14.6% higher than independent physicians. Most of the measures of primary care quality were not significantly different. CONCLUSIONS: Virginia patients, employers, and managed care companies incurred higher per-patient expenditures with hospital and health system physicians than with independent physicians.


Assuntos
Atenção à Saúde/economia , Gastos em Saúde/estatística & dados numéricos , Associações de Prática Independente/economia , Afiliação Institucional/economia , Qualidade da Assistência à Saúde/estatística & dados numéricos , Humanos , Estudos Retrospectivos , Virginia
4.
J Am Board Fam Med ; 31(4): 529-536, 2018.
Artigo em Inglês | MEDLINE | ID: mdl-29986978

RESUMO

BACKGROUND: Little is known about the prevalence and correlates of burnout among providers who work in small independent primary care practices (<5 providers). METHODS: We conducted a cross-sectional analysis by using data collected from 235 providers practicing in 174 small independent primary care practices in New York City. RESULTS: The rate of provider-reported burnout was 13.5%. Using bivariate logistic regression, we found higher adaptive reserve scores were associated with lower odds of burnout (odds ratio, 0.12; 95% CI, 0.02-0.85; P = .034). CONCLUSION: The burnout rate was relatively low among our sample of providers compared with previous surveys that focused primarily on larger practices. The independence and autonomy providers have in these small practices may provide some protection against symptoms of burnout. In addition, the relationship between adaptive reserve and lower rates of burnout point toward potential interventions for reducing burnout that include strengthening primary care practices' learning and development capacity.


Assuntos
Esgotamento Profissional/epidemiologia , Associações de Prática Independente/estatística & dados numéricos , Médicos de Atenção Primária/psicologia , Atenção Primária à Saúde/estatística & dados numéricos , Atitude do Pessoal de Saúde , Esgotamento Profissional/psicologia , Estudos Transversais/estatística & dados numéricos , Feminino , Humanos , Masculino , Cidade de Nova Iorque/epidemiologia , Médicos de Atenção Primária/estatística & dados numéricos , Prevalência , Atenção Primária à Saúde/organização & administração , Carga de Trabalho/psicologia , Carga de Trabalho/estatística & dados numéricos
6.
Tex Med ; 114(12): 22-25, 2018 Dec 01.
Artigo em Inglês | MEDLINE | ID: mdl-30605555

RESUMO

Can physicians line up venture capital without letting go of their independence? It's not so easy.


Assuntos
Financiamento de Capital , Associações de Prática Independente/economia , Médicos/economia , Humanos , Investimentos em Saúde , Texas
7.
Med Care ; 55(12): 1039-1045, 2017 12.
Artigo em Inglês | MEDLINE | ID: mdl-29068905

RESUMO

BACKGROUND: The belief that there is inefficiency, or the potential to improve patient health at current levels of spending, is driving the push for greater value in health care. Previous studies demonstrate overuse of a narrow set of services, suggesting provider inefficiency, but existing studies neither quantify inefficiency more broadly nor assess its variation across physician organizations (POs). DATA AND METHODS: We used data on quality of care and total cost of care from 129 California POs participating in a statewide value-based pay-for-performance program. We estimated a production function with quality as the output and cost as the input, using a stochastic frontier model, to develop a measure of relative efficiency for each PO. To validate the efficiency measure, we examined correlations of PO efficiency estimates with indicators representing overuse of services. RESULTS: The estimated production function showed that PO quality was positively associated with costs, although there were diminishing marginal returns to spending. A certain minimum level of spending was associated with high quality even among efficient POs. Most strikingly, however, POs had substantial variation in efficiency, producing widely differing levels of quality for the same cost. CONCLUSIONS: Differences among POs in the efficiency with which they produce quality suggest opportunities for improvements in care delivery that increase quality without increasing spending.


Assuntos
Eficiência Organizacional , Acessibilidade aos Serviços de Saúde/economia , Associações de Prática Independente/economia , Padrões de Prática Médica/economia , Qualidade da Assistência à Saúde/economia , California , Feminino , Pesquisa sobre Serviços de Saúde , Humanos , Masculino , Reembolso de Incentivo/economia
8.
9.
Healthc (Amst) ; 5(1-2): 46-52, 2017 Mar.
Artigo em Inglês | MEDLINE | ID: mdl-27618668

RESUMO

BACKGROUND: Value-based purchasing (VBP) favors provider organizations large enough to accept financial risk and develop care management infrastructure. Independent Practice Associations (IPAs) are a potential alternative for physicians to becoming employed by a hospital or large medical group. But little is known about IPAs. METHODS: We selected four IPAs that vary in location, structure, and strategy, and conducted interviews with their president and medical director, as well as with a hospital executive and health plan executive familiar with that IPA. RESULTS: The IPAs studied vary in size and sophistication, but overall are performing well and are highly regarded by hospital and health plan executives. IPAs can grow rapidly without the cost of purchasing and operating physician practices and make it possible for physicians to remain independent in their own practices while providing the scale and care management infrastructure to make it possible to succeed in VBP. However, it can be difficult for IPAs to gain cooperation from hundreds to thousands of independent physicians, and the need for capital for growth and care management infrastructure is increasing as VBP becomes more prevalent and more demanding. CONCLUSIONS: Some IPAs are succeeding at VBP. As VBP raises the performance bar, IPAs will have to demonstrate that they can achieve results equal to more highly capitalized and tightly structured large medical groups and hospital-owned practices. IMPLICATIONS: Physicians should be aware of IPAs as a potential option for participating in VBP. Payers are aware of IPAs; the Medicare ACO program and health insurer ACO programs include many IPAs.


Assuntos
Associações de Prática Independente/economia , Associações de Prática Independente/tendências , Médicos/organização & administração , Aquisição Baseada em Valor/economia , Humanos , Inquéritos e Questionários , Estados Unidos
10.
J Dent Hyg ; 90(4): 249-56, 2016 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-27551146

RESUMO

PURPOSE: The purpose of this cross-sectional, quantitative research was to examine if registered dental hygienists feel competent to work independently based on regulations of dental supervision. METHODS: A stratified sample of 360 dental hygienists from 8 states completed the Dempster Practice Behaviors Scale survey. ANOVA and MANOVA analyses revealed how state dentist supervision level, age, degree of education, employment status, gender and years of clinical experience affect the perceived autonomy of professional dental hygienists. RESULTS: The response rate included 360 dental hygienists from 8 states. According to the findings age, education level and gender affected the hygienist's level of autonomy. In all 8 states, the registered dental hygienists have a high level of autonomy and feel competent to work independently. CONCLUSION: The DPBS scores of the sample registered dental hygienists suggest that they feel prepared and competent to perform preventive dental hygiene services without dentist supervision. The attitudes of the dental hygienist sample from each of the 4 state dentist supervision levels supports a move toward achieving professional jurisdiction of preventive dental care within the U.S.


Assuntos
Atitude do Pessoal de Saúde , Higienistas Dentários/organização & administração , Autonomia Profissional , Prática Profissional/organização & administração , Adolescente , Adulto , Idoso , Estudos Transversais , Higienistas Dentários/psicologia , Odontólogos , Emprego , Feminino , Humanos , Associações de Prática Independente , Pessoa de Meia-Idade , Administração da Prática Odontológica , Inquéritos e Questionários , Estados Unidos , Adulto Jovem
11.
Medisan ; 20(8)ago.-ago. 2016. tab
Artigo em Espanhol | LILACS, CUMED | ID: lil-794100

RESUMO

Se efectuó un estudio de observación participante en 25 adultos mayores, quienes integraron el "Triángulo de la solidaridad, amor y salud", asociación independiente radicada en el Consejo Popular de Chicharrones, área de salud Municipal de Santiago de Cuba, a fin de contribuir al mejoramiento de la calidad de vida de estos ancianos, durante el 2014. Entre las técnicas y procedimientos empleados figuraron: observación y dinámica de grupo, las cuales integraron el programa desarrollado mensualmente. En la serie predominaron las féminas (96,0 %). Teniendo en cuenta que 54,1 % no pertenecían a grupos de adulto mayor, surgió la idea humanitaria e unipersonal de crear esta asociación y realizar actividades socioculturales en su entorno habitual para así fomentar su calidad de vida.


A participant observation study was made in 25 elderly who integrated the "Triangle of the solidarity, love and health", independent association from Chicharrones People´s Council, Municipal health area in Santiago de Cuba, in order to contribute to the improvement of these elderly life quality, during 2014. Among the techniques and used procedures there were: observation and group dynamics, which integrated the program developed monthly. In the series the female sex prevailed (96.0%). Taking into account that 54.1% didn't belong to elderly groups, the humanitarian and unipersonal idea arose to create this association and to carry out sociocultural activities in their usual environment in order to promote their life quality.


Assuntos
Qualidade de Vida , Idoso , Estilo de Vida , Associações de Prática Independente , Atividades de Lazer
12.
J Dent Hyg ; 90(3): 148-61, 2016 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-27340181

RESUMO

PURPOSE: This descriptive, comparative study was conducted to examine characteristics, services, models and opinions among collaborative dental hygiene practitioners in New Mexico and Minnesota. METHODS: A self-designed online questionnaire, distributed via SurveyMonkey®, was utilized to collect data from 73 subjects who met the inclusion criteria. A multi-phase administration process was followed. Content validity and reliability was established. Descriptive statistics were used for analysis of 6 research questions. The Mann-Whitney U, Pearson Chi-Square and Fisher's Exact tests were employed to analyze 4 null hypotheses (p=0.05). RESULTS: Most participants (n=36) were experienced clinicians who chose to work in an alternative setting after 28 years or more in the field and reported increased access to care as the reason for practicing collaboratively. A variety of services were offered and private insurance and Medicaid were accepted, although many practitioners did not receive direct reimbursement. The majority of New Mexico participants worked in private dental hygiene practices, earned advanced degrees and serviced Health Provider Shortage Areas. The majority of Minnesota respondents worked in various facilities, earned associate's degrees and were uncertain if Health Provider Shortage Areas were served. There were no significant differences in the variables between practitioners in both states. CONCLUSION: New Mexico and Minnesota collaborative dental hygiene practitioners are similar in characteristics, services, and opinions although models of practice vary. Collaborative dental hygiene practice is a viable answer to increasing access to care and is an option for patients who might otherwise go without care, including the unserved, underserved, uninsured and underinsured.


Assuntos
Assistência Odontológica/organização & administração , Acessibilidade aos Serviços de Saúde , Higiene Bucal , Adulto , Higienistas Dentários/legislação & jurisprudência , Feminino , Disparidades em Assistência à Saúde , Humanos , Associações de Prática Independente , Medicaid , Pessoa de Meia-Idade , Minnesota , New Mexico , Reprodutibilidade dos Testes , Inquéritos e Questionários , Estados Unidos , Adulto Jovem
15.
AANA J ; 83(3): 203-9, 2015 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-26137763

RESUMO

The purpose of this exploratory, descriptive study was to determine if moral distress levels differed between certified registered nurse anesthetists (CRNAs) working in medically supervised versus independent practice in California. A 63-question survey was administered to 1,190 California CRNAs. Moral distress was measured by the included Ethics Stress Scale. The response rate was 14.7%, yielding demographic and Ethics Stress scores for 175 respondents. Sixty-five participants answered an open-ended question about moral distress yielding qualitative data. Medically supervised CRNAs had a lower mean moral distress scores (176.8) versus independent practice CRNAs (187.8) (p = .002). Lower scores on the ESS indicate higher moral distress. Qualitative data demonstrated that CRNAs experienced moral distress in the following situations: when pressured to give anesthesia to unoptimized patients, when differences of opinion regarding anesthetic plans occurred, in dealing with end-of-life issues, when working with incompetent providers, and during interprofessional struggles between CRNAs and anesthesiologists. In order to reduce moral distress among CRNAs, implications for practice include increased administrative support, increased communication and reciprocated collegial respect between anesthesiologists and CRNAs, and CRNA representation on ethics committees.


Assuntos
Atitude do Pessoal de Saúde , Associações de Prática Independente/ética , Princípios Morais , Enfermeiros Anestesistas/ética , Enfermeiros Anestesistas/psicologia , Recursos Humanos de Enfermagem Hospitalar/ética , Recursos Humanos de Enfermagem Hospitalar/psicologia , Adulto , Idoso , California , Coleta de Dados , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Fatores Socioeconômicos , Estresse Psicológico , Adulto Jovem
16.
J Dent Educ ; 79(5): 465-71, 2015 May.
Artigo em Inglês | MEDLINE | ID: mdl-25941139

RESUMO

This Point/Counterpoint article discusses the transformation of dental practice from the traditional solo/small-group (partnership) model of the 1900s to large Dental Support Organizations (DSO) that support affiliated dental practices by providing nonclinical functions such as, but not limited to, accounting, human resources, marketing, and legal and practice management. Many feel that DSO-managed group practices (DMGPs) with employed providers will become the setting in which the majority of oral health care will be delivered in the future. Viewpoint 1 asserts that the traditional dental practice patterns of the past are shifting as many younger dentists gravitate toward employed positions in large group practices or the public sector. Although educational debt is relevant in predicting graduates' practice choices, other variables such as gender, race, and work-life balance play critical roles as well. Societal characteristics demonstrated by aging Gen Xers and those in the Millennial generation blend seamlessly with the opportunities DMGPs offer their employees. Viewpoint 2 contends the traditional model of dental care delivery-allowing entrepreneurial practitioners to make decisions in an autonomous setting-is changing but not to the degree nor as rapidly as Viewpoint 1 professes. Millennials entering the dental profession, with characteristics universally attributed to their generation, see value in the independence and flexibility that a traditional practice allows. Although DMGPs provide dentists one option for practice, several alternative delivery models offer current dentists and future dental school graduates many of the advantages of DMGPs while allowing them to maintain the independence and freedom a traditional practice provides.


Assuntos
Atenção à Saúde/tendências , Assistência Odontológica/tendências , Prática Odontológica de Grupo/tendências , Organizações de Serviços Gerenciais/tendências , Atitude do Pessoal de Saúde , Efeito de Coortes , Odontólogos/psicologia , Empreendedorismo , Previsões , Setor de Assistência à Saúde , Humanos , Associações de Prática Independente , Propriedade , Prática Privada , Autonomia Profissional , Corporações Profissionais , Setor Público
17.
J Dent Hyg ; 88(6): 373-9, 2014 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-25534690

RESUMO

PURPOSE: The purpose of this study was to determine the perceived level of preparedness Maine Independent Practice Dental Hygienists (IPDHs) received from their standard undergraduate dental hygiene education, and recognize areas necessary for further preparation in order to explore careers beyond the private practice dental model. METHODS: A convenience sample of 6 IPDHs participated in a survey exploring their educational experience in public health and alternative practice settings. The survey also asked for their recommendations to advance dental hygiene education to meet the needs of those wishing to pursue alternative practice careers. RESULTS: This study found that participants felt underprepared by their dental hygiene education with deficits in exposure to public health, business skills necessary for independent practice, communication training and understanding of situations which require referral for treatment beyond the IPDH scope of practice. CONCLUSION: As the dental hygiene profession evolves, dental hygiene education must as well. The IPDH participants' recommendations for dental hygiene programs include increased exposure to alternative settings and underserved populations as well as elective courses for those students interested in alternative practice and business ownership.


Assuntos
Higienistas Dentários/educação , Associações de Prática Independente/organização & administração , Gerenciamento da Prática Profissional/organização & administração , Prática Profissional/organização & administração , Adulto , Escolha da Profissão , Comércio/educação , Comunicação , Assistência Odontológica , Humanos , Relações Interprofissionais , Maine , Pessoa de Meia-Idade , Prática Privada , Saúde Pública/educação , Encaminhamento e Consulta
19.
JAMA ; 312(16): 1663-9, 2014.
Artigo em Inglês | MEDLINE | ID: mdl-25335148

RESUMO

IMPORTANCE: Hospitals are rapidly acquiring medical groups and physician practices. This consolidation may foster cooperation and thereby reduce expenditures, but also may lead to higher expenditures through greater use of hospital-based ambulatory services and through greater hospital pricing leverage against health insurers. OBJECTIVE: To determine whether total expenditures per patient were higher in physician organizations (integrated medical groups and independent practice associations) owned by local hospitals or multihospital systems compared with groups owned by participating physicians. DESIGN AND SETTING: Data were obtained on total expenditures for the care provided to 4.5 million patients treated by integrated medical groups and independent practice associations in California between 2009 and 2012. The patients were covered by commercial health maintenance organization (HMO) insurance and the data did not include patients covered by commercial preferred provider organization (PPO) insurance, Medicare, or Medicaid. MAIN OUTCOMES AND MEASURES: Total expenditures per patient annually, measured in terms of what insurers paid to the physician organizations for professional services, to hospitals for inpatient and outpatient procedures, to clinical laboratories for diagnostic tests, and to pharmaceutical manufacturers for drugs and biologics. EXPOSURES: Annual expenditures per patient were compared after adjusting for patient illness burden, geographic input costs, and organizational characteristics. RESULTS: Of the 158 organizations, 118 physician organizations (75%) were physician-owned and provided care for 3,065,551 patients, 19 organizations (12%) were owned by local hospitals and provided care for 728,608 patients, and 21 organizations (13%) were owned by multihospital systems and provided care for 693,254 patients. In 2012, physician-owned physician organizations had mean expenditures of $3066 per patient (95% CI, $2892 to $3240), hospital-owned physician organizations had mean expenditures of $4312 per patient (95% CI, $3768 to $4857), and physician organizations owned by multihospital systems had mean expenditures of $4776 (95% CI, $4349 to $5202) per patient. After adjusting for patient severity and other factors over the period, local hospital-owned physician organizations incurred expenditures per patient 10.3% (95% CI, 1.7% to 19.7%) higher than did physician-owned organizations (adjusted difference, $435 [95% CI, $105 to $766], P = .02). Organizations owned by multihospital systems incurred expenditures 19.8% (95% CI, 13.9% to 26.0%) higher (adjusted difference, $704 [95% CI,$512 to $895], P < .001) than physician-owned organizations. The largest physician organizations incurred expenditures per patient 9.2% (95% CI, 3.8% to 15.0%, P = .001) higher than the smallest organizations (adjusted difference, $130 [95% CI, $-32 to $292]). CONCLUSIONS AND RELEVANCE: From the perspective of the insurers and patients, between 2009 and 2012, hospital-owned physician organizations in California incurred higher expenditures for commercial HMO enrollees for professional, hospital, laboratory, pharmaceutical, and ancillary services than physician-owned organizations. Although organizational consolidation may increase some forms of care coordination, it may be associated with higher total expenditures.


Assuntos
Prática de Grupo/economia , Gastos em Saúde/estatística & dados numéricos , Sistemas Pré-Pagos de Saúde/economia , Associações de Prática Independente/economia , Propriedade , Médicos/economia , California , Economia Hospitalar , Humanos , Reembolso de Seguro de Saúde/economia , Índice de Gravidade de Doença
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